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Total talar dislocation, ie, disruption of the talus from the calcaneus, navicula, and tibia, is a rare and severe injury. We present a case of closed peritalar dislocation without any accompanying fractures and, thus, discuss the conflicts encountered in this rare injury. A 25-year-old male patient presented with severe pain, swelling, and deformity in his right ankle within 30 minutes of a fall from a height. There were no wounds around the ankle. Radiographs revealed that the talus was disrupted from the calcaneus, navicula, and tibia moving in the anterolateral direction. No accompanying fractures were seen in the talus or in surrounding bones. After an unsuccessful closed reduction attempt, a further decision was open reduction. It was seen that the interposed joint capsula was preventing reduction. After reduction, stability of the ankle was checked and found to be satisfactory, so no fixation material was used. It has been 2 years since the first injury, and the patient is functioning well, with no pain. The ankle has the same range of motion as the unaffected side. No sign of an avascular necrosis or sclerosis is seen on the final radiographs. Closed total dislocation of the talus without any accompanying fractures is a rare entity. The injury is open to various important complications, such as avascular necrosis, infection in patients with open wounds, and arthritic changes. To achieve a good outcome, early reduction of the dislocation has key importance. (J Am Podiatr Med Assoc 103(1): 73–75, 2013)
The Prevalence of Interdigital Erythrasma
A Prospective Study from an Outpatient Clinic in Turkey
Background
Erythrasma is a superficial skin infection caused by Corynebacterium minutissimum. Interdigital erythrasma is the most common form and is easily confused with tinea pedis. The aim of this study was to determine the prevalence of interdigital erythrasma in patients with clinically suspected tinea pedis.
Methods
This study was performed between January 1, 2011, and January 31, 2012. It included 182 patients who presented with concerns about interdigital lesions. All of the patients were examined with a Wood's lamp, and smears were stained with Gram's method. Direct examination with 20% potassium hydroxide was performed.
Results
Of 182 patients with interdigital lesions, 73 (40.1%) were diagnosed as having erythrasma. The mean ± SD age of the patients with erythrasma was 45.52 ± 10.83 years (range, 22–70 years). Most of the patients with erythrasma were women (56.2%). The most often clinical finding was desquamation. Using only Wood's lamp examination or Gram's staining resulted in 31 (42.5%) or 14 (19.2%) positive patients, respectively. Using Wood's lamp examination and Gram's staining concurrently resulted in 28 positive patients (38.4%).
Conclusions
Interdigital erythrasma is a common condition and can be difficult to differentiate from tinea pedis. Simple and rapid diagnosis can be made with Wood's lamp examination, but Gram's staining is also a useful method, especially in patients with negative Wood's lamp examination findings.
Background: Historically recalcitrant to treatment, infection of the nail unit is a pervasive clinical condition affecting approximately 10% to 20% of the US population; patients present with both cosmetic symptomatology and pain, with subsequent dystrophic morphology. To date, the presumptive infectious etiologies include classically reported fungal dermatophytes, nondermatophyte molds, and yeasts. Until now, the prevalence and potential contribution of bacteria to the clinical course of dystrophic nails had been relatively overlooked, if not dismissed. Previously, diagnosis had largely been made by means of clinical presentation, although microscopic examinations (potassium hydroxide) of nail scrapings to identify fungal agents and, more recently, panel-specific polymerase chain reaction assays have been used to elucidate causative infectious agents. Each of these tools suffers from test-specific limitations.
Methods: Molecular-age medicine now includes DNA-based tools to universally assess any microbe or pathogen with a known DNA sequence. This affords clinicians with rapid DNA sequencing technologies at their disposal. These sequencing-based diagnostic tools confer the accuracy of DNA-level certainty, and concurrently obviate cultivation or microbial phenotypical biases.
Results: Using DNA sequencing-based diagnostics, the results in this article document the first identification and quantification of significant bacterial, rather than mycotic, pathogens to the clinical manifestation of dystrophic nails.
Conclusions: In direct opposition to the prevailing and presumptive mycotic-based causes, the results in this article invoke questions about the very basis for our current standards of care, including effective treatment regimens.
Confirmation of Dermatophytes in Nail Specimens Using In-Office Dermatophyte Test Medium Cultures
Insights from a Multispecialty Survey
Using data from a multicenter nationwide multispecialty survey, the authors investigated the efficacy of in-office dermatophyte test medium (DTM) and central laboratory cultures used to confirm onychomycosis across samples collected by podiatric, dermatologic, and primary-care physicians. The samples collected by podiatric physicians were both positive or both negative in 43% and 27% of patients, respectively. Samples harvested by dermatologists were both positive in 37% of patients and both negative in 32%, while the samples collected by primary-care physicians were both positive in 28% of patients and both negative in 38%. The accuracy of DTM and central laboratory tests is dependent on the proper collection of nail samples, and the accuracy of mycologic test results varied significantly across nail specimens harvested by podiatric, dermatologic, and primary-care physicians. DTM culture was found to be an effective and convenient method of confirming dermatophyte infections in patients with signs of onychomycosis. The data presented here indicate that the special expertise of podiatric physicians in treating foot-related illnesses translates into more accurate mycologic testing. (J Am Podiatr Med Assoc 93(3): 195-202, 2003)
Background: We used a model of lower-extremity ulceration to determine the impact of a podiatric lead limb preservation team on identified relationships among risk factors, predictors of ulceration, amputation, and clinical outcomes of lower-extremity disease in patients with diabetes mellitus.
Methods: A total of 485 patients with diabetes mellitus were randomly selected from the diabetic population and included in this retrospective cohort study. Patients were then stratified into two groups: those who received specialty podiatric medical care and those who did not. Data covering a 5-year period were collected using electronic medical records and chart abstraction to capture detailed treatment characteristics, ulcer status, and surgical outcomes.
Results: Overall, the frequencies of inpatient and outpatient encounters and the durations of hospital stays were significantly greater with increasing wound depth and in the presence of infection. In addition, the overall ulcer incidence was greater in patients with callus (34.3% versus 10.3%, P < .0001) with and without neuropathy (20.4% and 4.1%, P < .0001). Among patients treated in a specialty multidiscipline podiatric medical setting, the proportion of all amputations that were “minor” was significantly increased (33.7% versus 67.3%, P = .0006), and survival was significantly improved (19.5% versus 7.7%, P < .0001).
Conclusions: Early identification of individuals at increased risk for lower-extremity ulceration and subsequent referral for advanced multidiscipline podiatric medical specialty care may decrease rates of ulceration and proximal amputation and improve survival in patients with diabetes mellitus who are at high risk for ulceration and limb loss. (J Am Podiatr Med Assoc 100(4): 235–241, 2010)
Osteomyelitis is one of the most feared sequelae of diabetic foot ulceration, which often leads to lower-extremity amputation and disability. Early diagnosis of osteomyelitis increases the likelihood of successful treatment and may limit the amount of bone resected, preserving ambulatory function. Although a variety of techniques exist for imaging the diabetic foot, standard radiography is still the only in-office imaging modality used today. However, radiographs lack sensitivity and specificity, making it difficult to diagnose bone infection at its early stages. In this report, we describe our initial experience with a cone beam computed tomography (CBCT)–based device, which may serve as an accurate and readily available tool for early diagnosis of osteomyelitis in a patient with diabetes. Two patients with infected diabetic foot ulcers were evaluated for osteomyelitis using radiography and CBCT. Positive imaging findings were confirmed by bone biopsy. In both patients, CBCT captured early osteolytic changes that were not apparent on radiographs, leading to early surgical intervention and successful treatment. The CBCT was helpful in facilitating detection and early clinical intervention for osteomyelitis in two diabetic patients with foot ulcers. These results are encouraging and warrant future evaluation.
Background
This study describes the technique for decompression of the intermetatarsal nerve in Morton's neuroma by ultrasound-guided surgical resection of the transverse intermetatarsal ligament. This technique is based on the premise that Morton's neuroma is primarily a nerve entrapment disease. As with other ultrasound-guided procedures, we believe that this technique is less traumatic, allowing earlier return to normal activity, with less patient discomfort than with traditional surgical techniques.
Methods
We performed a pilot study on 20 cadavers to ensure that the technique was safe and effective. No neurovascular damage was observed in any of the specimens. In the second phase, ultrasound-guided release of the transverse intermetatarsal ligament was performed on 56 patients through one small (1- to 2-mm) portal using local anesthesia and outpatient surgery.
Results
Of the 56 participants, 54 showed significant improvement and two did not improve, requiring further surgery (neurectomy). The postoperative wound was very small (1–2 mm). There were no cases of anesthesia of the interdigital space, and there were no infections.
Conclusions
The ultrasound-guided decompression of intermetatarsal nerve technique for Morton's neuroma by releasing the transverse intermetatarsal ligament is a safe, simple method with minimal morbidity, rapid recovery, and potential advantages over other surgical techniques. Surgical complications are minimal, but it is essential to establish a good indication because other biomechanical alterations to the foot can influence the functional outcome.
Background: Several absorbable and nonabsorbable antibiotic carrier systems are available in the adjunctive surgical management of osteomyelitis of the foot, ankle, and lower leg. These carrier systems have significant limitations regarding which antibiotics can be successfully incorporated into the carrier vehicle. The calcium sulfate and hydroxyapatite Cerament Bone Void Filler is a biocompatible, absorbable ceramic bone void filler that can successfully deliver multiple heat-stable and heat-unstable antibiotics that have not been generally used before with antibiotic beads in treating musculoskeletal infections.
Methods: Cerament Bone Void Filler discs with the antibiotics rifampin, vancomycin, tobramycin, cefazolin, cefepime hydrochloride, vancomycin-tobramycin, piperacillin-tazobactam, ceftazidime, and ticarcillin-clavulanate were tested in vitro against methicillin-resistant Staphylococcus aureus.
Results: The zones of inhibition for the Cerament Bone Void Filler antibiotic discs plated against Staphylococcus aureus obtained were 33% to 222% greater than the minimum zones of inhibition breakpoints for bacteria susceptibility as defined by the standard set by the Clinical and Laboratory Standards Institute. Cerament Bone Void Filler discs with the antibiotics plated against Pseudomonas aeruginosa produced zones of inhibition of 93% to 200% greater than the minimum zones of inhibition breakpoints for bacteria susceptibility as defined by the standard set by the Clinical and Laboratory Standards Institute.
Conclusions: The calcium sulfate and hydroxyapatite Cerament Bone Void Filler was an excellent carrier vehicle for multiple antibiotics creating in vitro significant zones of inhibition, thus demonstrating susceptibility against Staphylococcus aureus and Pseudomonas aeruginosa, which holds tremendous promise in treating osteomyeilits. (J Am Podiatr Med Assoc 101(2): 146–152, 2011)
Background:
Diabetic foot osteomyelitis is common and causes substantial morbidity, including major amputations, yet the optimal treatment approach is unclear. We evaluated an approach to limb salvage that combines early surgical debridement or limited amputation with antimicrobial therapy.
Methods:
We conducted a retrospective cohort study of patients treated between May 1, 2005, and May 31, 2007. The primary end point was cure, defined as not requiring further treatment for osteomyelitis of the affected limb. The secondary end point was limb salvage, defined as not requiring a below-the-knee amputation or a more proximal amputation.
Results:
Fifty patients with diabetic foot osteomyelitis met the study criteria. Initial surgical management included local amputation in 43 patients (86%) and debridement without amputation in seven (14%). Most infections (n = 30; 60%) were polymicrobial, and Staphylococcus aureus was the most common pathogen (n = 23; 46%). Parenteral antibiotics were used in 45 patients (90%). Patients who had pathologic evidence of osteomyelitis at the surgical margin received therapy for a median of 43 days (interquartile range [IQR], 36–56 days), whereas those without evidence of residual osteomyelitis received therapy for a median of 19 days (IQR, 13–40 days). Overall, 32 patients (64%) were considered cured after a median follow-up of 26 months (IQR, 12–38 months). Fifteen of 18 patients (83%) who failed initial therapy were treated again with limb-sparing surgery. Limb salvage was achieved in 47 patients (94%), with only three patients (6%) requiring below-the-knee amputation.
Conclusions:
In patients with diabetic foot osteomyelitis, surgical debridement or limited amputation plus antimicrobial therapy is effective at achieving clinical cure and limb salvage. (J Am Podiatr Med Assoc 102(4): 273–277, 2012)
Reconstruction of large bone defects of the metatarsals, whether resulting from trauma, infection, or a neoplastic process, can be especially challenging when attempting to maintain an anatomical parabola and basic biomechanical stability of the forefoot. We present the case of a 42-year-old man with no significant medical history who presented to the emergency department following a severe lawnmower injury to the left forefoot resulting in a large degloving type injury along the medial aspect of the left first ray extending to the level of the medial malleolus. The patient underwent emergent debridement with application of antibiotic bone cement, external fixation, and a negative-pressure dressing. He was subsequently treated with split-thickness skin graft and iliac crest tricortical autograft using a locking plate construct for reconstruction of the distal first ray. Although the patient failed to advance to radiographic osseous union, clinically there was no motion at the attempted fusion site and no pain with ambulation, suggestive of a pseudoarthrosis. The patient has since progressed to full nonpainful weightbearing in regular shoes and has returned to normal activities of daily living. The patient returned to his preinjury level of work and has had complete resolution of all wounds including his split-thickness skin graft donor site. This case shows the potential efficacy of the Masquelet technique for spanning significant traumatic bone defects of the metatarsals involving complete loss of the metatarsophalangeal joint.
